橈骨小頭半脫位

.,橈骨頭半脫位,邢臺縣醫(yī)院骨科許湞鋮,.,Whats橈骨頭半脫位？,.,專業(yè)回答,牽拉肘，也被稱作環(huán)狀韌帶移位或橈骨頭半脫位，是兒童常見的骨科損傷。IntheUnitedStates,theincidenceofemergencydepartmentvisitsforpulledelbowisestimatedat2.7per1000personsyoungerthan18yearsofage.Themedianageatpresentationis2years.在美國，未成年人急診就診中牽拉肘的發(fā)生率大約在2.7/1000.相關報道的中位年齡為2歲。Theinjuryisuniquetoinfantsandyoungchildrenbecausetheradialheadislessbulbousthanitisinolderpersonsandmayeasilybecomedisplaced.牽拉肘特別常見于嬰幼兒和青少年，因為幼兒的橈骨頭還未發(fā)育像成人那樣的圓球狀橈骨頭，所以很容易移位。Reductionofapulledelbowisasafeprocedurethatcanbeperformedintheoutpatientsetting.復位牽拉肘是相對安全的操作，完全可以在門診進行。Theannularligamentencirclestheneckoftheradiusandholdsittightlyinplaceagainsttheulna),therebymaintainingthepositionoftheproximalradiusinrelationtotheulnaandthecapitellumofthedistalhumeruswhileallowing180-degreerotation.環(huán)狀韌帶包繞橈骨頸使其緊鄰尺骨，從而維持橈骨與毗鄰尺骨以及肱骨遠端肱骨小頭的相對位置，同時可以完成180旋轉。Whenthereisforcefullongitudinaltraction,suchaswhenachildispulledorliftedbythearm,theradialheadispulledunderneaththeannularligament.在強大的縱向（軸向）牽拉下，比如提拉幼兒手臂或用手臂引體向上時，橈骨頭會被牽拉至環(huán)狀韌帶下方。,.,大多數(shù)孩子的病史中可能有過被牽拉的情況,.,.,環(huán)狀韌帶嵌壓的環(huán)狀韌帶,環(huán)狀韌帶包繞橈骨頸，并維持橈骨緊鄰尺骨,軸向牽拉時，橈骨頭包埋在環(huán)狀韌帶下,.,首先，明確孩子的病史及體檢與診斷一致。Thechildshistorymayincludeawitnessedeventofforcefultraction;however,othermechanismsofinjuryhavealsobeendescribed.孩子的病史中可能有過被牽拉的情況；然而，其它的損失機制也有描述過。Physicalexaminationshouldrevealpseudoparalysis,withthechildvoluntarilykeepingthelimbstilltominimizediscomfort.體格檢查會發(fā)現(xiàn)假性神經(jīng)麻痹，而孩子為了減少不適會自主保持上肢制動。Therewillalsobepainwithmovement,mostoftenrelatedtosupinationandpronationratherthantoflexionandextension.活動時疼痛，旋前或旋后較屈伸更易產生。Inmostcasestherewillbetendernesstopalpationonthelateralsideoftheelbow;however,absenceofthistendernessdoesnotruleoutthediagnosis.多數(shù)情況下觸診肘關節(jié)外側可及虛空感，即使未及虛空感也不能排除該診斷。Anaffectedchildholdstheelbowinaslightlyflexedposition,withthehandpronated.受傷的孩童將被迫保持肘關節(jié)輕微屈曲位并維持手掌旋前位。Furtherexaminationshouldalsorevealanormal-lookingelbowwithouteffusion,bruising,orobviousdeformity.更進一步的檢查則會發(fā)現(xiàn)肘關節(jié)外形正常，無突出，無挫傷或明顯的畸形。Radiographsarealmostalwaysnormalincasesofpulledelbow,soradiographyshouldbereservedforcasesinwhichthediagnosisisnotclear.,.,牽拉肘的影像學檢查幾乎都是正常的，所以只有在診斷不明確時才考慮進行影像學檢查。However,positioningtheelbowinpreparationforradiographyisoftentherapeuticinreducingthedisplacement.然而，在放置體位來進行影像學檢查時，往往對復位移位有幫助。Contraindications禁忌征ThecontraindicationstoperformingareductionarefewandareusuallyeasilyRecognized.復位的禁忌征很少且容易鑒別。Ifachildhasahistoryandphysicalexaminationthatareconsistentwithfracture,suchasdeformity,swelling,orbruisingoftheelboworahistoryofafallontothearmfromasubstantialheight,thenaradiographshouldbeobtainedtoevaluateforfracture.如果孩子的病史或體格檢查與骨折吻合，比如畸形，腫脹或肘關節(jié)挫傷或有高處摔落手臂著地的外傷史，則應行影像學檢查來判斷是否骨折。Iftheradiographdoesnotrevealfractureoreffusion,thenreductionmaybeconsidered.如果影像學檢查未發(fā)現(xiàn)骨折或突出，則可以考慮手法復位。,.,Inonestudy,reductionwasachievedonthefirstattemptin95%ofpatientswhounderwentrandomizationtohyperpronationascomparedwith77%ofpatientswhounderwentrandomizationtosupination.在一項研究中，隨機予以過度旋前手法首次復位成功的比例是95%，而旋后手法則為77%。SupinationTechnique旋后手法Toperformthesupinationtechnique,seatthechildontheparentorcaregiverslap,withthechildfacingyou.Claspboththehandandelbowoftheaffectedarm(圖.3).采用旋后手法時，讓孩子坐在家長或監(jiān)護人的大腿上面對著操作者?？圩』贾氖趾椭?。Yourfingersorthumbshouldoverlietheradialhead.Neitherthepositioningofyourfingersorthumbnorthestartingpositionoftheaffectedarmiscriticaltothesuccessoftheprocedure.操作者的手指后大拇指應壓在橈骨頭上。無論是操作者的手指或大拇指位置或患肢的初始位置對于復位成功都至關重要。,.,Supinateandflextheforearmuntilyoufeeltheligamentmovebackintoposition(圖.4).Youmayfeelorhearaclickastheligamentisreduced.旋前屈曲前臂直到感覺環(huán)狀韌帶移回至正常位置。環(huán)狀韌帶復位時操作者可以感覺或聽到輕微的咔噠聲。Ifthereductionissuccessful,thechildshouldbepainfreeandabletomovethearmnormallyin5to30minutes,includingbeingabletoreachforanobjectabovethehead.如果復位成功，孩子便會不痛并能在5-30分鐘內自如活動，包括碰觸高過頭頂?shù)奈矬w。HyperpronationTechnique過度旋前法Hyperpronationcanbetheprimarymethodusedtoreduceapulledelbow,oritcanbeusedifthesupinationtechniquehasfailed.Seatthechildontheparentsorcaregiverslap,withthechildfacingyou.However,ifanyotherabnormalitiesarepresent,suchasevidenceofinfection,reductionshouldnotbeattemptedandimmediateevaluationofthecauseandappropriatetreatmentshouldbeinitiated.但是，如果合并其它任何疾病，比如感染，則不能予以復位而應立即評估造成疾病的原因同時立即予以適當?shù)闹委煛?.,Preparation準備Noequipmentisrequiredforthereductionofapulledelbow.Theclinicianshandsshouldbewashedthoroughlyaspartofstandardprecautions.復位肘關節(jié)無需準備任何設備。臨床醫(yī)生徹底洗手應該是標準注意事項的一部分。Procedure操作Topreparetheparentorcaregiver,explainthatsomediscomfortmaybeassociatedwiththeprocedure.操作前告知家長或監(jiān)護人，操作過程中可能會造成一些不適。Thechildmaycryorscreamforseveralminutesaftertheradialheadhasbeenrelocatedtoitsproperposition.橈骨頭復位至正常位置后孩子可能會哭或喊叫一會。Twotechniquescanbeusedtocorrectapulledelbow.二種手法可以用來糾正牽拉肘。Thesupinationtechniquehastypicallybeenusedforreductionofpulledelbow;however,somestudiescomparingthesupinationwiththehyperpronationtechniquehaveshownthathyperpronationismoresuccessful.旋后法早已被用作為經(jīng)典的牽拉肘復位手法；然而，一些研究比較了旋后手法與過度旋前手法發(fā)現(xiàn)過度旋前法效果更好。,.,復位肘關節(jié)可以首選過度旋前法或在旋后手法未能復位時再選擇過度旋前手法。讓孩子坐在家長或監(jiān)護人的大腿上，面對著操作者。Claspthehandoftheaffectedarmasyouwouldinahandshake(圖.5).Useyourfreehandtosupportthepatientselbow.握住患肢像握手那樣。用另一只手拖住患者的肘部。Hyperpronatethepatientswrist(圖.6).Youmayfeelorhearaclickastheligamentisreduced.旋前患者手腕。韌帶復位時可以感覺或聽到輕微的咔噠聲。Ifthereductionissuccessful,thechildshouldbepainfreeandabletomovethearmnormallyin5to30minutes,includingbeingabletolifttheaffectedarmabovethehead.如果復位成功，孩子便會不痛并能在5-30分鐘內自如活動，包括碰觸高過頭頂?shù)奈矬w。Troubleshooting處理難題Mostreductionsofapulledelbowwillbesuccessfulafterasingleattempt.大多數(shù)的牽拉肘都能一次復位成功。,.,Ifaninitialattemptfails,theproceduremayberepeatedorthealternatetechniquemaybeused.如果初次復位失敗，可以再次嘗試復位或換一種復位手法。Iftheelbowhasnotbeenreducedafterthreeorfourattempts,reexaminethearmcarefullyfromshouldertofingertipsandobtainaradiographtoruleoutfracture.如果嘗試3-4次后仍無法復位肘關節(jié)，則應再次仔細檢查從肩膀至手指并予以行影像學檢查來排除骨折。However,whenthecauseoftheinjuryordisplacementisafall,whenthecircumstancesoftheinjuryareunclear,orwhenitisdifficulttoperformathoroughexaminationbecausethechildisuncooperative,itisprudenttoobtainaradiographbeforethethirdorfourthattemptatreduction.然而，當造成損傷或移位的原因是摔落，或損傷的周圍環(huán)境不清楚或則是因為孩子不配合而無法進行徹底的體格檢查時，在嘗試進行第三或第四次復位前為謹慎起見應進行影像學檢查。Afterobtainingaradiograph,splinttheelbowatanangleofapproximately90degrees(evenifthechildpresentswiththearmmorefullyextended)andreferthechildtoanorthopedicsurgeon.影像學檢查后，用夾板固定肘關節(jié)在大約90的位置（即使孩子開始的手臂是過伸位的），然后將孩子轉診至骨科醫(yī)生。,.,Inthemajorityofsuchcases,theaffectedelbowwillreducespontaneouslyduringtheperiodofimmobilization.對于多數(shù)此類情況，受傷的肘關節(jié)會在制動期間自發(fā)復位。Aftercare操作后護理Whenapulledelbowhasbeensuccessf